Ebook NMS surgery (6th edition) Part 1

(BQ) Part 1 book NMS surgery presentation of content: Principles of surgical physiology, essentials of general surgery, medical risk factors in surgical patients, principles of thoracic surgery, arterial disease, venous and lymphatic disease, stomach and duodenum, pancreas,...

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Na tiona l Me d ic a l Se rie s fo r Inde pe nde nt Stud y

NMS

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Stephen M Kavic, MD

Associate ProfessorDepartment of SurgeryProgram Director

Residency in General SurgeryUniversity of Maryland School of MedicineBaltimore, Maryland

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Library of Congress Cataloging-in-Publication Data

NMS surgery / [edited by] Bruce E Jarrell, Stephen M Kavic — Sixth edition.

p ; cm — (National medical series or independent study) National medical series surgery

Includes index.

ISBN 978-1-60831-584-0

I Jarrell, Bruce E., editor II Kavic, Stephen M (Stephen Michael), editor III itle: National medical series surgery IV Series: National medical series or independent study

[DNLM: 1 Surgical Procedures, Operative—Examination Questions 2 Surgical Procedures, Operative—Outlines 3 General Surgery—

methods—Examination Questions 4 General Surgery—methods—Outlines WO 18.2]

RD37.2 617.0076—dc23

Healthcare pro essionals, and not the publisher, are solely responsible or the use o this work including all medical judgments and or any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health in ormation, independent pro essional veri cation o medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare pro essionals should consult a variety o sources When prescribing medication, healthcare pro essionals are advised to consult the product

in ormation sheet (the manu acturer’s package insert) accompanying each drug to veri y, among other things, conditions o use, warnings, and side ef ects and identi y any changes in dosage schedule or contraindications, particularly i the medication to be administered is new,

in requently used, or has a narrow therapeutic range o the maximum extent permitted under applicable law, no responsibility is assumed

by the publisher or any injury and/or damage to persons or property, as a matter o products liability, negligence law or otherwise, or rom any re erence to or use by any person o this work.

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I wis h to tha nk m y wife , Le s lie , a nd m y wonde rful c hildre n for a ll of the ir

s upport during m y c a re e r, a nd for the ir unde rs ta nding during the writing of

the m a ny e ditions o f NMS Surge ry – BEJ

De dic a te d to m y loving wife J e nnife r a nd to m y love ly da ughte r Em ily – SMK

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It is with tremendous pride that I introduce the sixth edition o NMS Surgery T is work has occupied a central role in the education o a generation o medical students T e outline ormat makes it a superb re erence or those learning the basics o surgery and a thorough review or those who already practice our art

T e current edition has special signi cance to the University o Maryland School o Medicine

Dr Jarrell is the Chie Academic and Research O cer and Dean o the Graduate School He also was my predecessor as Chair o the Department o Surgery Dr Kavic is the current program director o our surgery residency T e chapter authors and contributors include a virtual directory

o our trainees and aculty It is a privilege to be associated with these esteemed educators

I am continually impressed by the talents o the surgeons and surgeons-in-training at the University o Maryland T at quality is re ected in the ollowing chapters I know that you will enjoy this edition as much as I take pride in it

Ba ltim ore , Ma ryla nd

vi

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Pre ace

Welcome to the sixth edition o NMS Surgery

T is book aims to build on the legacy o the previous ve editions We have retained much o the organization and ormat rom the last versions At the same time, we have strived to make this volume more readable

It is an increasing challenge to limit content in the ace o rapidly expanding surgical knowledge As

in previous editions, the text is not meant to be all-inclusive but rather serves as an introduction or the student o surgery All o the chapters have been thoroughly reviewed, rewritten, and updated

to re ect the current state o the art in surgery

T ere are dramatic dif erences in the ormat o this volume Perhaps most importantly, each section now begins with “Chapter Cuts and Caveats,” which are some o the most important principles

worthy o the reader’s attention Within each chapter, we have added “Quick Cuts,” which are highlights that have been brought out separately rom the text In addition, we have added a new section at the end, “Grade A Cuts,” which are pairings that highlight associations in surgical thinking

For the tremendous work put into this edition, we are indebted to the authors T eir high-quality and requently punctual contributions have made our jobs as editors pleasant We are also grate ul

to the editorial team at Wolters Kluwer or their guidance and support throughout the process

T e sixth edition o NMS Surgery is written primarily or students and residents in general surgery, but practicing surgeons as well as physicians in other specialties will no doubt nd it a use ul

re erence We hope that all readers will nd that the book represents a declaration o the state o surgical art in 2015

—Bruc e E J a rre ll, MD

—Ste phe n M Ka vic , MD

vii

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Willia m R Ale x, MD, FACS

Cardiothoracic SurgeryRiverside, Cali ornia

H Ric ha rd Ale xa nde r, MD, FACS

Pro essor o SurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

Andre a C Ba fford , MD, FACS

Assistant Pro essor o SurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

Em ily Be lla va nc e , MD, FACS

Hugo Bona tti, MD, FACS

General and Minimally Invasive SurgeryEaston, Maryland

Che rif Boutros , MB, CHB, MSc , FACS

Associate Pro essor o SurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

J o na tha n Brom b e rg, MB, PhD, FACS

Pro essor o SurgeryChie

Division o ransplantationUniversity o Maryland School o MedicineBaltimore, Maryland

Bra ndo n Bruns , MD, FACS

La ura S Buc ha na n, MD, FACS

Whitne y Burro ws , MD, FACS

Clint D Ca pp ie llo, MD

Resident in SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Ke nne th M Cra nda ll, MD

Resident in NeurosurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Rob e rt S Cra wfo rd, MD, FACS

Pe te r E Da rwin, MD

Pro essor o MedicineUniversity o Maryland School o MedicineBaltimore, Maryland

Ga rim a Dos i, MD

Fellow in Vascular SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Ric ha rd N Edie , MD, FACS

Cardiothoracic SurgeryPhiladelphia, Pennsylvania

Ste ve n Fe ige nb e rg, MD

Pro essor o Radiation OncologyUniversity o Maryland School o MedicineBaltimore, Maryland

viii

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J e s s ic a Fe lton, MD

J a m e s S Ga m m ie , MD, FACS

Pro essor o SurgeryChie , Division o Cardiac SurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

J inny Ha , MD

Na ta s ha Ha ns ra j, MD

And re a He be rt, MD

Resident in OtolaryngologyUniversity o Maryland Medical CenterBaltimore, Maryland

Tripp Holto n, MD, FACS

He le n G Hui-Chou, MD

Fellow in Plastic SurgeryUniversity o MarylandJohns Hopkins UniversityBaltimore, Maryland

Aja y J a in, MD, FACS

Associate Pro essor o SurgeryState University o New York Upstate Medical UniversitySyracuse, New York

Ste ve n B J ohns on, MD, FACS, FCCM

Pro essor and ChairmanDepartment o SurgeryUniversity o ArizonaPhoenix, Arizona

J e s s ic a J oine s , MA, MGC

Instructor o MedicineUniversity o Maryland School o MedicineBaltimore, Maryland

Ste phe n M Ka vic , MD, FACS

Associate Pro essor o SurgeryProgram Director

Residency in General SurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

Ed win Ke ndric k, MD

Fellow in Vascular SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Sus a n B Ke s m o de l, MD, FACS

Ma rk D Kligm a n, MD, FACS

And re w Kra m e r, MD, FACS

Na ta lia Kubic ki, MD

Ka the rine G La m ond, MD, FACS

Ma tthe w Lis s a ue r, MD, FACS, FCCM

Associate Pro essor o SurgeryRutgers Robert Wood Johnson Medical SchoolNew Brunswick, New Jersey

Da nie l E Ma ns our, MD

Da nie l Me dina , MD, P hD

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Ma yur Na ra ya n, MD, MPH, MBA, FACS

Silke Nie de rha us , MD, FACS

D Bruc e Pa na s uk, MD, FACS

Chie o SurgeryWilmington VA Medical CenterWilmington, Delaware

J ona tha n P P e a rl, MD, FACS

Srine va s K Re ddy, MD, FACS

Surgical Oncology and Hepatobiliary SurgeryMinneapolis, Minnesota

Da nie l Re znic e k, MD

Resident in Urologic SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Erne s t L Ros a to, MD, FACS

Pro essor o SurgeryDirector

Division o General Surgery

T omas Jef erson UniversityPhiladelphia, Pennsylvania

Fra nc is E Ros a to J r, MD, FACS

General and Minimally Invasive SurgeryPennington, New Jersey

Cha rle s A Sa ns ur, MD

Assistant Pro essor o NeurosurgeryUniversity o Maryland School o MedicineBaltimore, Maryland

J os e p h R Sc a le a , MD

ransplant Surgery FellowUniversity o WisconsinMadison, Wisconsin

Ma x Se a ton, MD

De vinde r Sing h, MD, FACS

Ale xis D Sm ith, MD

Rob e rt Ste rling, MD

Assistant Pro essor o SurgeryJohns Hopkins University School o MedicineBaltimore, Maryland

Eric Stra uc h, MD, FACS

Olive r Ta nnous , MD

Resident in Orthopedic SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

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J ulia Te rhune , MD

Dougla s J Turne r, MD, FACS

Ke li Turne r, MD

A Cla ire Wa tkins , MD

Resident in Cardiothoracic SurgeryUniversity o Maryland Medical CenterBaltimore, Maryland

Rona ld J We ig e l, MD, PhD, MBA, FACS

Pro essor and Chair o SurgeryUniversity o Iowa

Iowa City, Iowa

Niluka A Wic kra m a ra tne , MD

Resident in SurgeryVirginia Commonwealth UniversityRichmond, Virginia

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Preface viiAcknowledgmentsContributors viii

1 P rinc ip le s o f Surg ic a l P hys io lo g y 3

Ste ve n B J o hns on a nd Ma tthe w Lis s a ue rFluid and Electrolytes 3

Acid–Base Disturbances 11Coagulation 13

Packed Red Blood Cell rans usion T erapy 16Nutrition and the Surgical Patient 17

T e Intensive Care Unit 22Shock 27

2 Es s e ntia ls o f Ge ne ra l Surg e ry 30

Na ta s ha Ha ns ra j a nd Dougla s J Turne rWounds 30

Surgical ubes and Drains 33Hernias 35

Postoperative Complications 39Surgical In ections 40

Gastrointestinal Fistula 41

3 Me d ic a l Ris k Fa c to rs in Surg ic a l P a tie nts 43

Sus a n B Ke s m ode l, Na ta lia Kubic ki, a nd Ma yur Na ra ya nGeneral Aspects or Evaluation and Management o the Surgical Patient 43Evaluation o the Surgical Patient with Cardiac Disease 46

Evaluation o the Surgical Patient with Lung Disease 51Evaluation o the Surgical Patient with Renal Disease 53Evaluation o the Surgical Patient with Liver Disease 55

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4 Life -thre a te ning Dis o rd e rs : Ac ute Ab d o m ina l

Surg ic a l Em e rge nc ie s 58

La ura S Buc ha na n a nd J os e J Dia zAcute Abdomen 58

Obstruction 63Hemorrhage 65

Study Questions or Part I 67Answers and Explanations 73

5 P rinc ip le s o f Tho ra c ic Surg e ry 78

J inny Ha a nd Whitne y BurrowsGeneral Principles o T oracic Surgery 78Chest Wall Disorders 83

Pleural and Pleural Space Disorders 83Pulmonary In ections 85

Solitary Pulmonary Nodules (Coin Lesions) 85Bronchogenic Carcinoma 85

Bronchial Adenomas 88Metastatic umor 89 racheal Disorders 89Mediastinal Lesions 90

7 Arte ria l Dis e a s e 118

Ga rim a Dos i a nd Robe rt S Cra wfordGeneral Principles 118

Lower Extremity Arterial Occlusive Disease 118Aortoiliac Occlusive Disease (AIOD) 120

Femoropopliteal Occlusive Disease 122

In rageniculate ibial Disease 123Acute Arterial Insu ciency 124Amputations 125

Extracranial Cerebrovascular Disease 125

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Aortic Dissection 127Arterial Aneurysms 128Mesenteric Vascular Disease 130Renal Artery Stenosis 132

Miscellaneous 133

8 Ve no us a nd Lym p ha tic Dis e a s e 135

Ed win Ke ndric k a nd Ra ja bra ta Sa rka rAcute Deep Venous T rombosis 135

Acute Pulmonary Embolism 138Chronic Venous Disorders: Varicose Veins and Chronic Venous Insu ciency 140Super cial Venous T rombophlebitis 142

Esophageal umors 158Esophageal Per oration 160Mallory-Weiss Syndrome 160

10 Sto m a c h a nd Duo d e num 161

Che rif Boutros , Erne s t L Ros a to, a nd Fra nc is E Ros a to J r

Stomach 161Peptic Ulcer Disease 163Gastric Cancer 168

Postgastrectomy Syndromes 170Benign Stomach Lesions 171Gastritis 171

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12 Co lo n, Re c tum , a nd Anus 180

J ulia Te rhune a nd Andre a C Ba ffordIntroduction 180

Evaluation 182Bowel Preparation 184Benign and Malignant Colorectal umors 184Diverticular Disease 189

Angiodysplasia 192

In ammatory Bowel Disease 192Pseudomembranous Colitis (Antibiotic-Associated Colitis) 196Ischemic Colitis 196

Volvulus 197Anorectal Dys unction 198Benign Anorectal Disease 199Perianal and Anal Canal Neoplasms 202

13 Live r, Ga llb la d d e r, a nd Bilia ry Tre e 204

Da nie l Me dina a nd Srine va s K Re d dyGeneral Aspects 204

Hepatic umors 207Hepatic Abscesses and Cysts 209Gallbladder Pathology 212

Biliary ree Pathology 213

14 P a nc re a s 215

H Ric ha rd Ale xa nde r, P e te r E Da rwin, a nd Ro na ld J We ige lAnatomy and Physiology 215

Pancreatitis 217Pancreatic Malignancies 225

15 Sp le e n 230

Da nie l E Ma ns our, Ma yur Na ra ya n, a nd Aja y J a inIntroduction 230

Pathology 231 echnical Aspects o Splenectomy 234Complications a er Splenectomy 235

Study Questions or Part IV 237Answers and Explanations 248

16 Bre a s t 256

Em ily Be lla va nc e , Ste ve n Fe ige nbe rg , a nd J e s s ic a J oine sIntroduction 256

Breast Evaluation 256Benign Breast Disease 259Malignant Diseases 260

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17 Thyro id , P a ra thyro id , Ad re na l Gla nd s , a nd Thym us 266

J ohn A Ols on J r

T yroid Gland 266Abnormalities o T yroid Descent 268

T yroid Dys unction Requiring Surgery 269Parathyroid Glands 276

Adrenal Gland 279 umors o the Endocrine Pancreas 285Multiple Endocrine Neoplasia 287

Congenital Masses 302Acquired Lesions 305Head and Neck In ections 308Malignant Lesions o the Head and Neck 308Neck Cancer 311

Nasal Cavity and Paranasal Sinus Cancer 312Nasopharynx Cancer 313

Oral Cavity Cancer 314Oropharynx Cancer 315Hypopharynx and Cervical Esophagus Cancer 316Larynx Cancer 317

Skin Cancer 318Head and Neck Lymphoma 319Unusual umors 320

Parotid Gland 320Evaluation and Management o Parotid Masses 322Parotid Neoplasms 322

Parotid rauma 323

In ammatory Disorders 324

19 Ba ria tric Surg e ry 326

Ma rk D Kligm a nBackground 325Surgical reatment o Obesity 326Postoperative Mortality and Complications 329

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20 Minim a l Ac c e s s Surg e ry 335

Da nie l Me dina , Hug o Bona tti, a nd Ste phe n M Ka vicHistory 335

General Principles 335Selected Laparoscopic Procedures 338Robotic echnology 343

Surgical reatment 348Multidisciplinary reatment 350Research and raining 351

22 Tra um a a nd Burns 352

Bra ndon Bruns a nd Thom a s Sc a le a rauma 352

Speci c Injuries 354Burns 359

23 Org a n Tra ns p la nta tio n 362

J os e p h R Sc a le a , Ma x Se a ton, Silke Nie de rha us , a nd J ona tha n Brom be rgOverview 362

Intestinal Atresia 385Hirschsprung Disease 387Disorders o In ancy 390Solid umors 395

Study Questions or Part VI 397Answers and Explanations 405

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Pa rt VII: Surgic a l Sub s pe c ia ltie s

Urologic rauma 427

26 P la s tic a nd Re c o ns truc tive Surg e ry 430

Niluka A Wic kra m a ra tne , He le n G Hui-Chou, De vinde r Singh, a nd Tripp HoltonOverview 430

Reconstructive Plastic Surgery 430Wound Healing and Diseases o Skin and So issue 442Cranio acial Surgery 444

Hand Surgery 445Aesthetic Plastic Surgery 446Innovations and Devices in Plastic Surgery 449

27 Ne uro s urg e ry 450

Ke nne th M Cra nda ll a nd Cha rle s A Sa ns urAnatomy 450

Pathophysiology 451Evaluating the Neurosurgical Patient 453Head Injury 454

Spinal Cord Injury 457Central Nervous System umors 462Congenital Nervous System Lesions 466Functional Neurosurgery 466

Degenerative Spine Disease 467Spine umors 470

Arthritis 486

In ections 488 umors 489Adult Orthopedics 491

Study Questions or Part VII 494Answers and Explanations 499

Appe nd ix A Gra de “A” Cuts 503 Ind e x 509

xviii Contents

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Part I

Intr du t n

CHAPTER 1

Princ iple s o Surgic a l P hys iology:

Management s k pat ents requ res resus tat n, w th the g al rest rat n per us n

Qu kly and a urately f nd ng the s ur e the l n al deter rat n and f x ng that pr blem s

ru al; therw se, the resus tat n w ll ult mately a l t all w adequate xygen del very

Sh k s the state phys l g de mpensat n result ng n nadequate t ssue per us n ( xygen demand utstr ps xygen supply)

Ult mately, n ne rmula best determ nes p st perat ve u d and ele tr lyte management

H gh nsens ble l sses (b th evap rat ve l sses and leakage nt the th rd spa e) ur dur ng and

a er surg al pr edures that nv lve pen b dy av t es; that are nvas ve and pen many t ssue planes; that are pr l nged; that are ass ated w th seps s, n ammat ry nd t ns, and s hem a rgans; that result n hyp tens n; and that are d ne n emergent sett ngs

Hyperkalem a must be treated aggress vely t av d l e-threaten ng arrhythm as T e best emergent treatment s IV b arb nate and IV nsul n and glu se, wh h m ves p tass um ntra ellularly and l wers serum levels IV al um s als use ul by a e t ng the thresh ld r

a t n p tent al and de reas ng ard a membrane ex tab l ty

Adequate xygenat n s assessed by m re than bl d pressure and pulse It s als m n t red by assess ng markers t ssue per us n (ur ne utput and renal un t n), xygenat n ( hest x-ray and lung aus ultat n r s gns pulm nary edema, bl d xygenat n, and ther measures), serum ele tr lyte levels, pH, arrhythm as, mentat n, external s gns hydrat n state, hemat r t, and the pat ent’s verall appearan e

When evaluat ng a pat ent wh s l n ally deter rat ng, always pr r t ze the evaluat n

d agn ses n y ur d erent al that w ll lead t the astest and greatest deter rat n

New anem a n a p st perat ve pat ent s surg al bleed ng unt l pr ven therw se Pa ked RBC trans us n pr v des ex ellent phys l g supp rt but has s de e e ts n lud ng allerg rea t ns and the p tent al r n e t us transm ss n—treat blood like a drug! Cler al err r s the m st

mm n ause r trans us n rea t n

Enteral nutr t n s pre erred n m st pat ents T e r sk entral ven us atheters utwe ghs nutr t nal benef ts r sh rt-term supplementat n nutr t nal supp rt s needed r less than

1 week L w album n levels rrelate w th m rtal ty

Pat ents w th nadequate xygenat n r n reased w rk breath ng sh uld have vent lat ry supp rt: When in doubt, intubate

CHAPTER 2

Es s e ntia ls o Ge ne ra l Surg e ry:

F r w und n e t ns: Abs ess must be dra ned, ne r t t ssue must be debr ded, rep tus suggests a ne r t z ng gas- rm ng n e t n demand ng that the w und be pened, re gn b d es ( n lud ng tubes r dra ns) must be rem ved, and enter leak must be ntr lled

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System ant b t s are n t the pr mary treatment r w und n e t ns

Per perat ve ant b t s g ven t pat ents w th lean- ntam nated w unds (wh h are usually

l sed pr mar ly) redu e the n den e w und n e t ns and the subsequent r sk hern a

Any nd t n that nter eres w th the ur phases w und heal ng (hem stas s, n ammat n,

pr l erat n, and rem del ng) w ll mpa r the rate heal ng and the f nal w und strength B th

l al and system a t rs have an e e t

L al a t rs: W unds sh uld be ree bleed ng, hemat ma, gr ss ntam nat n, and ne r t

t ssue; w und edges sh uld be ree tens n; and l al t ssue sh uld be healthy and well vas ular zed

System a t rs that mpa r w und heal ng: metab l sm, p r nutr t nal state, z n and v tam ns

A and C def en y, presen e n e t n, hyp x a, l w- w states, sm k ng, p rly ntr lled

d abetes, bes ty, llagen vas ular d seases, and renal and l ver a lureMed at ns: system glu rt ds, s me hem therapeut and mmun suppress ve drugs, and ang genes s nh b t rs

P st perat ve evers may result r m the 5 W’s: w und, water, w nd, walk ng, and w nder drugs

Surg al s te n e t ns are a maj r s ur e m rb d ty and are m st mm nly due t sk n ra (espe ally Staphylococcus)

N nheal ng GI f stulas may result r m FRIEND ( re gn b dy, rad at n, n ammat n,

ep thel al zat n, ne plas a, d stal bstru t n) and en resp nd t n n perat ve management

CHAPTER 3

Me dic a l Ris k Fa c tors in Surgic a l Pa tie nts :

Assessment med al r sk r nvas ve surg al pr edures n ludes a th r ugh h st ry, phys al, and lab rat ry exam nat n

Pat ents w th ard a nd t ns are at n reased r sk r ard a mpl at ns ll w ng

n n ard a surgery, and standard zed lass f at n systems help strat y r sk Fun t nal apa ty

m re than 4 ME s pred ts a l w r sk p st perat ve ard a events Ele t ve surgery sh uld be

p stp ned at least 4 weeks ll w ng acute ard a events r revas ular zat n

All pat ents sh uld be assessed r the degree r sk r ven us thr mb emb l events, and

pr phylax s w th hepar n s appr pr ate r m st surg al pat ents

CHAPTER 4

Li e -Thre a te ning Dis o rde rs : Ac ute Ab dom ina l Surgic a l Em e rge nc ie s :

When evaluat ng a pat ent r a ute abd m nal pa n, f rst determ ne whether the pat ent has a surg al abd men n exam nat n, judged by a d stressed pat ent w th pa n that s severe and general zed and ass ated w th reb und r guard ng Cl n al judgment s supplemented by rad graph stud es, su h as extralum nal per t neal ree a r, and lab rat ry stud es, su h as

f nd ngs supp rt ve s hem a, n ammat n, a ute hem rrhage nt the per t neal av ty,

r n e t n I the judgment a surg al abd men s made, mmed ate ntervent n a er resus tat n s nd ated

GI hem rrhage ne ess tates l al z ng the bleed ng and rmulat ng a plan t ntr l t be re surgery Ident y ng the s ur e bleed ng n the perat ng r m by evaluat ng the external sur a e the GI tra t s very d ult

manage a s gn f ant GI hem rrhage, balan ng three pr blems s multane usly be mes

ne essary: v lume resus tat n, agulat n de e t rre t n, and dent f at n and ntr l the s te hem rrhage rans us n bl d and bl d pr du ts may be r t al n manag ng all three pr blems rans us n bey nd several un ts results n n reased m rb d ty and m rtal ty

be ause bl d and ts pr du ts have many p tent al s de e e ts, su h as trans us n rea t ns w th anaphylax s and hem lys s, n e t us agent transm ss n, and mmune suppress n, am ng thers

L at n an nd ate mm n path l gy: RUQ suggests the b l ary tree; RLQ, the append x; and LLQ, the s gm d l n

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FLUID AND ELECTROLYTES

Norm a l Bo dy Co m p os itio n

I Body wa te r: Water a unts r 50%–70% b dy we ght (the

h gher per entage n y ung pe ple, th n pe ple, and man—the

l wer per entage n lder pe ple, bese pe ple, and w men)

B dy water s d v ded nt var us ntra ellular and extra ellular mpartments (F g 1-1)

A w -th rds rule: T s s a s mple meth d appr x mat ng

mpartment v lume be ause the var at n am ng pat ents and w th n the same pat ent tal b dy water mpr ses sl ghtly less than tw -th rds b dy we ght

B Plasma v lume: Us ng the ab ve rule, 5% b dy we ght s

plasma v lume (e.g., 3.5 L r a 70-kg male) Plasma s 60%

the bl d v lume ( the hemat r t s 40%); there re, the 70-kg male has 5 L bl d

II Ele c trolyte c om pos ition: Ele tr lytes determ ne the am unt water that ex sts n any ne spa e at any t me, and the r n entrat ns and mp s t ns d er between ntra ellular and extra ellular spa es due t n pumps (pr n pally Na /K A Pase), as sh wn n able 1-1

Change n sm t pressure n ne mpartment auses water t red str bute r m the ther mpartments t rega n equ l br um

A Intracellular (pr nc pal sm t c cat n s p tass um): has

h gher n entrat n sm t and n t (pr te n) part les than the extra ellular mpartment, thus all w ng water t w

nt the ell, reat ng turg d ty

B Extracellular (pr nc pal sm t c cat n s s d um): Interst t al

and plasma mp s t n s nearly but n t qu te dent al

Wa te r a nd Ele c tro lyte Ma inte na nc e

I Wa te r: Requ red am unt depends n the pers n’s we ght, age, gender, and llness

A Water calculat n meth ds

1 Am unt b dy water excreted

a M st water l st r m the b dy s thr ugh ur ne

pr du t n; generally, 0.5 mL/kg/hr s the m n mum needed t ex rete the da ly s lute l ad

Pr n ples Surg al Phys l gy

Steven B Johnson and Matthew Lissauer

Quic k Cut

The compartments are important becaus e

calculating f uid los s es , blood los ses , and amount o res us citation needed is key to ens uring patients ’ s urvival.

Quic k Cut

Two-thirds rule: Total body water (slightly less than) two-thirds total body weight.

Quic k Cut

O total body water, two thirds is intracellular and one third extracellular (three ourths inters titial and one ourth intravas cular).

Quic k Cut

Water ollows electrolytes acros s cell membranes to equilibrate

os molality.

Quic k Cut

Adequate urine output is ½ mL/kg/hr, or about 250 mL/8 hr in adults

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4 Chapter 1 Flu d and Ele tr lytes

Tota l body wa te r: 60% of tota l body we ight

Extra ce llula r: 20% of tota l body we ight (1/3 of the tota l body wa te r)

Intra ce llula r: 40% of tota l body we ight (2/3 of the tota l body wa te r)

Inte rs titia l: 15% tota l body we ight (3/4 of the e xtra ce llula r fluid)

Pla s ma : 5% tota l body weight (1/4 of the

e xtra ce llula r fluid)

Fig ure 1-1: Water compartments

Ta b le 1-1: Ele c tro lyte Com p os itio n o Va rious Wa te r Com pa rtm e nts

Ele c tro lyte s Intra c e llula r Co m p a rtm e nt Extra c e llula r Co m p a rtm e nt

Anio ns

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b T e next h ghest da ly water l ss s nsens ble l ss ( e., sweat, resp rat n, st l), wh h s

est mated as 600–900 mL/24 hr

c M n mal water ma ntenan e r a 70-kg man: (70 kg 0.5 mL/kg/hr 24 h urs)

750 mL/24 hr 1,590 mL/24 hr (Aga n, th s s the m n mum and d es n t take nt a unt any ex ess l ss su h as ever, wh h w ll n rease the nsens ble l ss.)

2 B dy we ght: T s meth d s en used r ped atr pat ents

be ause the r b dy we ghts vary w dely; est mat ns are

100 mL/kg/day r 4 mL/kg/hr r the f rst 10 kg b dy

we ght, 50 mL/kg/day r 2 mL/kg/hr r the se nd 10 kg

b dy we ght, and 20 mL/kg/day r 1 mL/kg/hr r ea h add t nal k l gram b dy we ght

3 G ven am unt water per k l gram b dy we ght: T e

value used r th s meth d s generally 35–40 mL/kg/day, adjusted h gher r l wer based n age ( lder adults en requ re nly 15 mL/kg/24-hr ma ntenan e due t h gher at/

l wer mus le mass)

B Evaluat ng ma ntenance rates: Pat ents n t nly have d erent

ma ntenan e needs, but repla ng water r rem v ng ex ess water may als be n ern (see I C 1) S mple meth ds n the noncritically ll p pulat n t m n t r adequa y u d adm n strat n n lude the ll w ng:

1 Ur ne utput var at ns: I ur ne utput s h gh

( e., 1 mL/kg/hr), then less water may be requ red;

ur ne utput s l w, m re water may be requ red, r urther assessment may be ne essary

2 achycard a: an be a s gn dehydrat n r l w

ntravas ular v lume

C Adjust ng f u d rates and type r nd v dual pat ents: F rst,

al ulate the pat ent’s ma ntenan e rate, then adjust the am unt

up r d wn based n the need r resus tat n, r repla ement gastr ntest nal (GI) l sses, and the type based n type

l sses ( able 1-2)

1 Injury, llness, and surgery: Can result n u d l sses due t bl d l ss, th rd spa ng, nsens ble

l sses r m d arrhea, ever, et Pr v d ng m re than al ulated ma ntenan e u d t repla e

l sses (e.g., 1.5 r 2 ma ntenan e) s ne essary, and rate adequa y an be judged r m the

ab ve r ter a

2 Hyperv lem a and d ures s: Pat ents wh requ re d ures s already are verl aded w th

lu d, and ntraven us (IV) lu ds sh uld be w thheld; h wever, ele tr lyte r nutr t nal aspe ts lu d adm n strat n may requ re water as a arr er r ther substan es dur ng

d ures s

Quic k Cut

Remember the shortcut or estimating f uid maintenance: The rst 20 kg

o weight 60 mL/hr and then

1 mL/kg/hr above that, so a 60-kg person 100 mL/hr.

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Becaus e water requirements vary Fever, environmental temperature, and res piratory rate can increas e ins ens ible los s and increas e maintenance requirements

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Older adults may not produce as much urine as the young and can be pushed into congestive heart ailure (CHF).

Ta b le 1-2: Ele c tro lyte Co m p os itio n o Ga s trointe s tina l Se c re tions

Org a n Vo lum e /d a y Na (m Eq /L) K (m Eq /L) Cl (m Eq /L) HCO 3 (m Eq /L)

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II Sodium : N rmally, pe ple take 150–200 mEq s d um da ly,

mu h wh h s ex reted n the ur ne

A I the b dy needs t nserve s d um, t an redu e renal

ex ret n t less than 1 mEq/day

B Da ly h me stas s s eas ly ma nta ned w th 1–2 mEq/kg/day.

III Pota s s ium : T e n rmal da ly ntake p tass um s 40–120

mEq/day, w th ab ut 10%–15% ex reted n ur ne; an am unt 0.5–1 mEq/kg/day s appr pr ate t ma nta n h me stas s

IV Ma inte na nc e IV: able 1-3 g ves ele tr lyte n entrat ns

several IV u ds Us ng the prev us est mates r a 70-kg male, the

we ght rmula r IV u d w uld equal 110 mL/hr

A M n mal s d um ma ntenan e w uld requ re 70–140 mEq/day,

and m n mal p tass um requ rements w uld be 35–70 mEq/day

B I 0.5% n rmal sal ne (NS) has 77 mEq/L s d um and 20 mEq/L

p tass um are added, then us ng 0.5% NS w th 20 mEq/L

p tass um hl r de at 110 mL/hr w uld equal ab ut 2.6 L u d,

200 mEq s d um, and 52 mEq p tass um pretty l se!

Wa te r a nd Ele c tro lyte De f c its a nd Exc e s s e s

I Wa te r

A Hyp v lem a

1 S gns acute v lume l ss: n lude ta hy ard a, hyp tens n,

and de reased ur ne utput

2 S gns gradual v lume l ss: n lude l ss sk n turg r, th rst,

alterat ns n b dy temperature, and hanges n mental status

3 Replac ng water de c ts: A ute def ts sh uld be repla ed

a utely; hr n def ts sh uld be repla ed m re sl wly, w th hal the def t repla ed ver the f rst 8 h urs and the rest n 24–48 h urs

B Hyperv lem a: well t lerated n healthy pat ents, wh w ll just

ur nate the ex ess

1 S gns acute hyperv lem a: a ute sh rtness breath,

ta hy ard a

2 S gns chr n c hyperv lem a: per pheral edema,

pulm nary edema

II Sodium : l se relat nsh p t v lume status

A Hyp natrem a (Na 130 mEq/L): F gure 1-2

1 Causes

a Hyper sm lar: hypergly em a, mann t l n us n, r presen e

ther sm t ally a t ve part les that draw n water

Quic k Cut

In the cas e

o hypernatremia with hypovolemia, do not allow the

s odium concentration to drop more than 0.5–1 mEq/hr.

Ta b le 1-3: Ele c tro lyte Co nc e ntra tion in Va rious Intra ve nous Fluid s

Fluid

Na (m Eq /L)

K (m Eq /L)

La c ta te (m Eq /L)

Os m o la rity (m Os m /L)

Normal saline (0.9% NaCl)

½ normal saline (0.5% NaCl)

Hypertonic saline (3% saline)

Quic k Cut

For a hyponatremia workup, rs t check the s erum

os molar value then, i needed, volume s tatus

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Diures is may be needed in s ome chronically hypervolemic patients to reduce volume.

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b N rm - sm lar (pseud hyp natrem a):

Hypertr gly er dem a, hyperl p dem a, and hyperpr te nem a;

large, m n mally sm t m le ules displace water and nter ere w th the lab measurement s d um

c Hyp - sm lar (1) Hyp v lem c: renal l sses, renal tubular a d s s,

erebral salt wast ng, GI l sses, “tea and t ast syndr me,” trans utane us l sses (burns, trauma)

(2) Hyperv lem c: T e path l gy s en related t

l w ard a utput (the k dneys see less bl d w, and ree water s nserved) r hyp album nem (e.g., rrh s s) r ther edemat us states where salt (ren n-ang tens n system) and ree water (ant d uret h rm ne [ADH]) ann t be ex reted

by the k dneys (e.g., renal a lure, CHF, nephr t syndr me)

(3) Euv lem c: uld be e ther the states ment ned

earl er, r (m re requently n the per perat ve

pat ent) syndr me nappr pr ate ant d uret c

h rm ne (SIADH) secret n, r thers

(e.g., glu rt d def en y, hyp thyr d sm, water

nt x at n [psy h gen p lyd ps a])

2 Sympt ms

a Acute hyp natrem a: ass ated w th a ute erebral

edema, se zures, and ma

b Chr n c hyp natrem a: Well t lerated t Na n entrat ns 110 mEq/L; sympt ms generally n lude n us n/de reased mental status, rr tab l ty, and de reased deep tend n

re exes

3 D agn s s and categ r zat n: Cl n al exam and lab determ nat n sm lar state are en

en ugh r d agn s s, but, n d ubt (espe ally w th hyp - sm lar hyp natrem a), he k ur ne

sm lar ty and s d um n entrat n

a Hyp v lem c, hyp - sm lar hyp natrem a: ur ne Na greater than 20 mEq/L renal

l sses, less than 10 mEq/L extrarenal l sses

b Hyperv lem c, hyp - sm lar hyp natrem a: ur ne Na greater than 20 mEq/L renal

a lure; Na less than 10 mEq/L rrh s s, heart a lure

c Euv lem c, hyp - sm lar hyp natrem a: ur ne sm lar ty usually h gh; ur ne Na usually greater than 20 mEq/L ex ept n water nt x at n

Quic k Cut

Do not give NaCl

or hyponatremia unles s hypovolemia is pres ent.

Quic k Cut

In hypovolemic hypo-os molar hyponatremia, total body s odium is als o

us ually low, whereas in hypervolemic hypo-os molar hyponatremia, total body

s odium is us ually high.

Quic k Cut

ADH s ecretion can be s timulated by the

s tres s respons e to trauma and s urgery, caus ing ree water retention and, in turn, euvolemic hypo-os molar hyponatremia.

Hypona tre mia

Hype ros motic Normo-os motic

Hypo-os motic

Hype rvole mic

Fig ure 1-2: Hyponatremia.

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4 reatment ( m n mally sympt mat c)

a Hyper sm lar: C rre t hypergly em a r s ur e ther

a t vely sm t part les

b N rm - sm lar: reat the underly ng d sease pr ess.

c Hyp - sm lar (1) Hyp v lem c: reat w th s t n u d n us n t

rest re u d and s d um def ts

(2) Hyperv lem c: reat underly ng med al ause

f rst, then usually salt and ree water restr t ns are appr pr ate

(3) Euv lem c: F rst determ ne the true ause s ne

the prev usly ment ned states; SIADH s the ause, ree water restr t n usually s en ugh (d not repla e salt n s lut n, wh h an parad x ally l wer serum

s d um, as the k dney ex retes s d um and nserves water)

B Hypernatrem a (Na 150 mEq/L)

1 Categ r es

a Hyp v lem a: Hypernatrem a alm st always represents a

ree water def t; t tal b dy s d um may be l w

b Hyperv lem a: Iatr gen n us n t mu h s d um

an lead t hyperv lem hypernatrem a, but th s s rare

2 Sympt ms: Can n lude th se v lume deplet n

(e.g., ta hy ard a, hyp tens n) as well as ther s gns dehydrat n (e.g., dry mu us membranes, de reased sk n turg r); lethargy, n us n, and ma result r m water sh s r m the ntra ellular mpartment n the entral nerv us system (CNS)

3 D agn s s/et l gy (usually s mple): h gh serum s d um w th bv us ree water l sses; n

surg al pat ents, u d l sses may be:

a Extrarenal: nsens ble l sses due t ever, me han al vent lat n, burns, d arrhea, r

measured l sses r m the GI tra t

b Renal: ex ess ve ree water ex ret n (1) Osm t d ures s r m hypergly em a r mann t l adm n strat n (2) H gh- utput d lute ur ne r m the p lyur phase a ute tubular ne r s s (A N)

4 reatment

a Hyp v lem a: Need t repla e v lume; al ulate ree water def t f rst:

(1) Water de c t 0.6 b dy we ght (kg) (serum Na /140 1) (2) Repla e hal the def t n the f rst 8 h urs and the rema nder n the next 16 h urs.

(3) I the hyp v lem state s severe ( e., sh k), n t al resus tat n an be s t n u ds;

the def t s less severe, r n e per us n s adequate and the def t reversed, sw t h t dextr se 5% n water (D5W) t mplete the ree water repla ement

b Hyperv lem a (1) I the pat ent’s t tal b dy water s n reased, f rst

de rease the am unt s d um adm n stered

(2) I s d um ntake (e.g., ant b t s, t tal parenteral

nutr t n [ PN]) ann t be de reased, ree water an

be n used t l wer the serum s d um level, but th s

d es n t de rease the t tal b dy s d um r water ntent

(3) D uret s an be used, but s d um an r se.

(4) Als ns der natr ures s

III Po ta s s ium

A Hyp kalem a (K 3.5 mEq/L): Severe hyp kalem a s def ned as a serum p tass um level

3.0 mEq/L r less; n s me pat ents ( ard a ), a K h gher than 4.0 s des rable

1 Sympt ms: In lude leus and weakness, and pr und deplet n results n ard a dysrhythm as

Ele tr ard gram (ECG) hanges an be me man est bel w a K 3.0 mEq/L and n lude, n

n reas ng rder sever ty, -wave atten ng r nvers n, depressed S segments, devel pment

Quic k Cut

I the s odium

de cit is severe with

hypo-os molar, hypovolemic hyponatremia, hypertonic

s odium replacement can be cons idered.

Quic k Cut

Giving hypertonic

s odium to patients with SIADH can make them wors e

The patient will excrete the

s odium via the kidneys and hold on to the water.

Quic k Cut

Giving uros emide

to hypernatremic patients can rais e the s odium

concentration, even in hypervolemic s tates Us e ree water to equilibrate the

s odium concentration prior to diures is

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U waves, pr l nged Q nterval, and f nally ventr ular

ta hy ard a

2 D agn s s/et l gy (s mple and based n bl d chem stry):

rarely und n healthy humans w th a n rmal d et and

n rmal k dneys; auses all n ne ur ateg r es:

a Renal: d uret s, v m t ng (renal ex ret n K t preserve Na ), renal tubular a d s s

b Extrarenal: d arrhea, burns

c Intracellular sh : nsul n, alkal t state

d Med cal d sease: hyperald ster n sm, Cush ng syndr me

3 reatment

a I sympt ms are severe, adm n ster p tass um IV as

needed t redu e sympt ms

b I sympt ms are m ld, n use 20 mEq/hr max mum n the

unm n t red pat ent and 40 mEq/hr n the m n t red pat ent

c Adm n strat n r m re hr n nd t ns an be v a the

enteral r ute

B Hyperkalem a (K 6 mEq/L)

1 Sympt ms: Rare but n lude d arrhea, ramp ng,

nerv usness, weakness, and a d paralys s; m re en, ard a dysrhythm as are man est be re ther sympt ms

be me severe, and ECG hanges n lude peaked waves

and w dened QRS and an eventually degenerate nt ventr ular f br llat n

2 D agn s s/et l gy (numer us): am ng the m re mm n

(2) Gluc se/ nsul n adm n strat n an be used t sh

K ntra ellularly a utely and qu kly (1 ampule D50

w th 10 un ts regular nsul n s en en ugh)

(3) B carb nate adm n strat n w ll als sh K

ntra ellularly

b rem ve K and t l wer b dy st res permanently:

(1) I n-ex hange res n: used e ther by m uth r re tally

and b nds K n the l n, a l tat ng ex ret n

(2) Fur sem de: nly use k dneys are able t ex rete and l sely m n t r ther ele tr lytes

and u d balan e

(3) D alys s

IV Chloride

A Hyp chl rem a (Cl 90 mEq/L)

1 Sympt ms: usually ass ated w th dehydrat n r hyp kalem a due t v m t ng r ther GI l ss

2 D agn s s/et l gy

a St ma h hydr hl r a d (HCl) s l st r m v m t ng, lead ng t l w hl r de and a bu ldup

b arb nate, aus ng a metab l c alkal s s.

b It s en ass ated w th parad x c ac dur a N rmally, the k dneys w uld ex rete

b arb nate t redu e pH; h wever, as the dehydrat n w rsens, the k dneys’ dr ve t reta n

s d um pred m nates, and the k dney ex retes b th K and H t nserve s d um

Quic k Cut

Remember, s erum

K concentration is not an indication o total body s tores

o potas s ium I the s erum

K is repleted but total body

s tores are low, s erum K will drop again quickly as K

s hi ts into cells

Quic k Cut

Acutely, the goal

is to s tabilize the cardiac membrane and to lower

s erum potas s ium in the hypokalemic patient Once the patient is s tabilized, maneuvers to remove K permanently rom the body

s hould be ins tituted.

Quic k Cut

A general rule o thumb is that every 10 mEq

o IV K s hould rais e s erum concentration by 0.1 mEq/L.

Quic k Cut

More important than diagnos ing hypokalemia is unders tanding the caus e.

Trang 30

3 reatment: Repla e the hl r de and v lume def t w th s d um hl r de s lut ns and repla e

K as needed

B Hyperchl rem a (Cl 110 mEq/L)

1 Cause: T e m st mm n ause n surg al pat ents s the

adm n strat n large am unts hl r de n IV s lut ns (the hl r de ntent n n rmal sal ne [154 mEq/L] s

s gn f antly h gher than that n plasma [90–110 mEq/L])

2 D agn s s/et l gy (easy—check the bl d chem stry):

Ex ess hl r de de reases the str ng n d eren e, thereby aus ng m re water t d ss ate and m re H ns t be present, lead ng t metab l a d s s

3 reatment: De rease the am unt hl r de be ng n used; l k r all s ur es (IV ant b t s)

n add t n t IV u ds ( s t n sal ne needs t be adm n stered r ther reas ns, ns der

s d um b arb nate r s d um a etate t redu e hl r de l ad [e.g., ½ NS w th 1.5 amps NaHCO3 /L has 152 mEq/L Na , nly 77 mEq/L hl r de, and 75 mEq/L b arb nate])

V Ca lc ium

A Hyp calcem a (Ca 8 mg/dL)

1 Sympt ms: In lude neur mus ular rr tab l ty w th per ral

and extrem ty numbness that may pr gress t arp pedal spasm and tetany; premature ventr ular ntra t ns an be redu ed w th treatment hyp al em a as pr l ngat n the Q nterval s n ted n these pat ents

2 D agn s s/et l gy (numer us)

a Surg cal pat ents: Suppress n n rmal parathyr d un t n r m the rem val

aden mat us r hyperplast glands s m st mm n, ll wed by a dental damage the parathyr ds dur ng thyr d surgery

b Cr t cally ll pat ents: la tate, trate r m bl d trans us ns, and numer us med nes

c Other: v tam n D def en y, hr n renal a lure, ntest nal malabs rpt n, ex ess d etary r

therapeut (laxat ve) magnes um, mer ury exp sure, helat n therapy

3 reatment

a Asympt mat c utpat ents: Can be supplemented rally— nvest gate p ss ble med al auses

(see prev us d s uss n)

b Sympt mat c pat ents: M n t r and treat.

(1) I sympt ms are m ld, large d ses ral al um are en adequate (espe ally n the

p stparathyr de t my pat ent)

(2) Severely sympt mat pat ents sh uld be repleted w th IV al um unt l sympt ms res lve

and an appr pr ate ral reg men s t lerated

B Hypercalcem a (Ca 10.5 mg/dL)

1 Sympt ms: Fat gue, n us n, nausea, v m t ng, d arrhea, dehydrat n, and an rex a are

mm n; when related t hyperparathyr d sm, renal al ul and ul er d sease are m re

mm n

2 D agn s s/et l gy (numer us)

a End cr ne: pr mary hyperparathyr d sm (m st mm n), thyr t x s s

b Mal gnancy: m st mm n (up t 20%–30% an er pat ents), en r m ste lyt r

parathyr d h rm ne–related pr te n (P HrP)–se ret ng les ns

c Granul mat us d sease: sar d s s, tuber ul s s

d Med cat ns: ex ess al um ngest n, v tam n D t x ty, th az de d uret s

e Other: renal d sease, m lk alkal syndr me, am l al hyp al ur hyp al em a

3 reatment

a F rst-l ne therapy: Aggress ve s t n resus tat n,

lead ng t d ures s and al um ex ret n; unsu ess ul,

ur sem de an be added

b Med cal therapy: Med at ns t st p ste last a t v ty

are the ma nstream ( e., b sph sph nates, al t n n, and ster ds are all used; pl a amy n s n l nger ava lable n the Un ted States)

Quic k Cut

Clas s ic s igns

o hypocalcemia include Trous s eau and Chvos tek

s igns (carpopedal s pas m and cheek twitch).

Quic k Cut

Severe, symptomatic hypercalcemia is a medical emergency and requires immediate treatment.

Quic k Cut

Remember that NS has 154 mEq Cl Generating

a hyperchloremic metabolic acidos is is eas y i too much

s aline is us ed.

Trang 31

ACID–BASE DISTURBANCES

Re g ula to ry Sys te m s

I Ca rbon dioxide : CO2 pr du t n an ex eed 15,000 mm l/

day r m metab l pr esses (e.g., lung ex ret n) I Pco2

n reases, water d ss ates and HCO3 and H rm based n the

Henders n-Hasselbalch equat n, thus de reas ng pH T e reverse

happens r l wer Pco2 n entrat ns E ther a l ss b arb nate

r a ga n n pr t ns an ause a d s s

II Strong io ns : I ns that mpletely d ss ate n water (e.g., Na ,

Cl , Ca , Mg , K ) In a pure salt s lut n, n n entrat ns are equal, and pH s neutral, whereas n plasma, at ns utnumber

an ns ma nta n ele tr al neutral ty, water d ss ates, H s

ex reted, and HCO3 n entrat n n reases, reat ng a pH 7.4,

n t 7.0

III We a k a c ids : Weak a ds an ex st as negat vely harged m le ules

r a ept H and ex st un harged T ese bu er ng systems n lude

1 Decreased vent lat n leads t n reased CO2 n entrat n Any ause depressed resp rat ns

an ause th s path l gy

2 Increased CO2 pr duct n Ex ess enteral r parenteral arb hydrate adm n strat n an

n rease the resp rat ry qu t ent and pr du t n CO2 H sp tal zed pat ents may n t be able t mpensate

B reatment: T e pr mary meth d r resp rat ry a d s s s t n rease alve lar vent lat n In ases

drug verd se, th s may be a mpl shed w th appr pr ate revers ng agents; h wever, m st alve lar hyp vent lat n requ res ntubat n w th me han al vent lat n t lear CO2 and return the

pH t n rmal values

II Me ta bolic a c idos is results e ther r m HCO3 l ss r a umulat n str ng an ns (measured r n nmeasured) r weak a ds

A Causes

1 Weak ac d accumulat n (an n gap): Et l gy n ludes l ss

HCO3 t ma nta n ele tr neutral ty

a A d a umulat n an ur be ause renal a lure and

the nab l ty the k dneys t lear a d by-pr du ts metab l sm

b Lact c ac d s s: A mm n ause s la t a d, wh h

results r m nadequate t ssue per us n and anaer b metab l sm

c D abet c ket ac d s s: A et a etate and beta-hydr xybutyrate are weak a ds.

d x ns (p lyethylene glyc l, methan l): Methan l s metab l zed t rmaldehyde and then

rm a d

2 Str ng an n accumulat n: n rmal an n gap

a Hyperchl rem c ac d s s: Ex ess hl r de ndu es water t d ss ate, H t a umulate, and

pH t dr p

3 L ss b carb nate: n rmal an n gap

a Ex ess renal ex ret n b arb nate

b D arrhea

Quic k Cut

The human body requires a very narrow pH range o 7.35–7.45 to unction properly Three main s ys tems

in the body maintain the pH within normal parameters : carbon dioxide, s trong ions , and weak acids

Quic k Cut

The Has s elbalch equation: pH

pK log [HCO3 /(0.03

P CO2)].

Quic k Cut

Acidosis is a lowering proces s ; acidemia is

pH-a low blood pH.

Quic k Cut

To determine the etiology o metabolic acidos is , check the anion gap I high, remember CUTE DIMPLES: cyanide, uremia, toluene, ethanol, diabetic ketoacidosis, isoniazid, methanol, propylene glycol, lactic acidos is , ethylene glycol, s alicylates

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12 Chapter 1 A d–Base D sturban es

B reatment: T e pr mary treatment r metab l a d s s s rre t n the underly ng metab l

pr blem/d sease and pr per u d and ele tr lyte management B arb nate adm n strat n sh uld rarely be used unless pH s danger usly l w ( 7.2) and the underly ng de e t s be ng rre ted (ex ept n: I the pr mary de e t s ex ess l ss b arb nate [d arrhea, renal tubular a d s s],

b arb nate therapy uld be ns dered)

Alka los is

I Re s p ira tory a lka los is

A Causes

1 Sp ntane usly breath ng pat ent: aused by alve lar

vent lat n n rease and subsequent redu t n n CO2 levels (anx ety, pa n, sh k, seps s, t x substan es [sal ylate

1 M st mm n n n atr gen ause metab l alkal s s s l ss gastr ntents (HCl and

large v lumes water are l st) mpensate r dehydrat n, the k dney ex retes H t nserve Na (parad x cal ac dur a) T e n entrat n str ng an ns s redu ed, and water s

less l kely t d ss ate, urther de reas ng H and n reas ng pH

2 Other causes

a Drugs that l m t renal ex ret n HCO3 (e.g., ster ds and d uret s)

b Overadm n strat n alkal (e.g., n ul er therapy), a etate

n PN that s used t repla e ther an ns, and trate n trans used bl d that s nverted t CO2 and water and then t HCO3 by the k dneys

B reatment: T e f rst step s t st p the l ss hl r de and t

repla e the water and hl r de w th s t n s d um hl r de and p tass um supplementat n F r ther auses, st pp ng the end ng agent s usually su ent

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Some proces s es (think of pulmonary

embolus!) caus ing hypoxia

or intrapulmonary s hunts can lead to hypocarbia and alkalos is

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Pa ra do xic a l

a c id uria : The kidney exchanges H or Na , s o the urine may be acidic but the patient alkalotic.

Ta ble 1-4: Ac id–ba s e Dis o rd e rs

Dis o rd e r P CO2 HCO 3 p H Exp e c te d Co m p e ns a tio n

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He m o s ta s is Me c ha nis m Pha s e s

I Prim a ry he m o s ta s is

A Platelet adherence: T e f rst step n ntr ll ng hem rrhage s platelet adheren e t the njured

vessel v a gly pr te n (Gp) re ept r Ib n njun t n w th v n W llebrand a t r

B Platelet act vat n: A t vated platelets pr du e thr mb xane A2 and ther vas nstr t rs, wh h redu e bl d w thr ugh the njured vessel Gp IIb/IIIa s expressed, wh h pr m tes platelet–platelet

adhes n (f br n gen requ red) and platelet plug rmat n.

II Clot o rm a tio n: ssue a t r exp sed due t vessel njury r n resp nse t n ammat n beg ns the

cl tt ng cascade (trad t nally taught as hav ng an ntr ns and extr ns pathway; h wever, n v v ,

b th pathways a t n n ert)

A Extr ns c pathway: ssue a t r b nds a t r VII and a t vates

t (VIIa) VIIa subsequently a t vates a t r X Xa then nverts

pr thr mb n t thr mb n

B Intr ns c pathway: In general, a t r XIIa a t vates XI, then

XIa a t vates IX IX then nverges w th the extr ns pathway

by a t vat ng a t r X T s pathway an be n t ated e ther by exp sure t a negat vely harged sur a e (exp sed llagen r m

a damaged vessel) r thr mb n tsel a t vates a t r IX

C B th pathways c nverge at act r X: Fa t r Xa then med ates

nvers n pr thr mb n t thr mb n w th a t r Va as a a t r

T r mb n med ates f br n gen nvers n t f br n F nally, a t r XIIIa med ates r ss-l nk ng f br n

III Re gula tio n a nd f brino lys is : T e agulat n system s

a cascade, mean ng that ea h a t vated ntermed ate a t r s able t a t vate many the a t rs

n subsequent steps T r mb n tsel a ts as a p s t ve eedba k l p by a t vat ng a t r IX T e

f br n lyt system a ts t balan e the agulat n as ade and t rem ve l ts n e heal ng has started

A ssue a t r pathway nh b t r ( FPI) may nh b t F–VIIa mplexes.

1 Pr te n C and pr te n S degrade a t rs V and VIII.

2 Ant thr mb n III nh b ts thr mb n-Xa mplexes.

3 F br n lys s: ssue-type plasm n gen a t vat r (t-PA) and ur k nase-type plasm n gen

a t vat r (uPA) med ate nvers n plasm n gen t plasm n, wh h leaves f br n

Coa g ulo pa thy

I His to ry: Lab stud es sh uld n t be r ut nely rdered pre perat vely

n a pat ent w th a negat ve h st ry, whereas n a p s t ve h st ry, stud es an be used t spe y the d agn s s

A Include any pat ent-perce ved c agul pathy: bru s ng,

pete h a, easy bleed ng/n sebleeds, h st ry bleed ng r m ther pr edures (dental/surg al)

B Fam ly h st ry

C Med cal c nd t ns/r sk act rs: l ver d sease ( rrh s s), renal a lure (urem a)

II Phys ic a l: ev den e bru s ng r pete h aIII La bo ra tory e va lua tion

A Platelet c unt: n rmal s 150,000–400,000/mL bl d

B Bleed ng t me: Measure platelet un t n D s rders platelet

un t n n lude urem a, drugs (asp r n, l p d grel, Gp II B/III A

nh b t rs), v n W llebrand d sease, and l w platelet unt

C Pr thr mb n t me: P measures the extr ns as ade Be ause

a t rs II (thr mb n), VII, and X are pr du ed by the l ver, P represents a g d measure v tam n K–dependent agulat n

a t rs and s there re used t m n t r war ar n therapy T e nternat nal n rmal zed rat (INR) s a n rmal zat n a t r t equate lab values between labs

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The extrins ic s ys tem

us ually begins the clotting cas cade Components o the extrins ic sys tem als o activate the intrinsic s ys tem.

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The extrinsic pathway is ref ected in the

p ro thro m b in tim e (PT).

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The his tory is the mos t important tool to diagnos e a coagulopathy.

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Platelets higher than 100,000 are neces s ary or major s urgery Keep higher than 50,000/mL or general hemos tasis Counts les s than 10,000/mL put patients at ris k

or s pontaneous bleeding.

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14 Chapter 1 C agulat n

D Act vated part al thr mb plast n t me (aP ): measures

the ntr ns as ade and s use ul r ll w ng pat ents n IV

un ra t nated hepar n therapy

E T r mb n t me: ests the nvers n f br n gen t f br n

v a thr mb n; t s elevated when f br n gen s depleted r

n n un t n ng and n the presen e hepar n

F T r mb elast gram ( EG): measures h l st ally l t

rmat n and breakd wn k net s

G Act vated cl tt ng t me (AC ): rap dly determ nes e e t

h gh-d se hepar n; used n ard a surgery

H Ant - act r Xa act v ty: used t m n t r l w-m le ular-we ght hepar n a t v ty

Spe c if c Hyp oc o a g ulo p a thic Sta te s

I Firs t, e ns ure ble e ding is not a s urgic a l c o m plic a tion: D n t ne essar ly blame p st perat ve bleed ng n agul pathy unt l surg al bleed ng s ruled ut

II Live r dis e a s e : In severe l ver d sease, hepat ytes ann t manu a ture l tt ng a t rs P /INR s

elevated reatment n ludes repla ng a t rs w th resh r zen plasma (FFP) Chr n ally, v tam n K

an mpr ve hepat synthet un t n

III Re na l dis e a s e : Urem a auses platelet dys un t n reatment an be w th DDAVP, wh h auses

release v n W llebrand a t r r FFP

IV Dis s e m ina te d intra va s c ula r c oa gulop a thy (DIC): M r vas ular agulat n due t

n ammat n r m seps s, trauma, and ther severe nsults leads t a nsumpt n and def t

a t rs, lead ng t agul pathy T e ma nstay treatment n ludes treat ng the underly ng ause

Repla ement a t rs may exa erbate the nd t n; parad x ally, ant agulant therapy may be benef al

V Cons um ption/dilution

A Due t severe trauma, seps s, maj r surgery, and the r attendant u d resus tat n; treatment

nv lves rre t ng the underly ng ause and repla ng a t rs w th FFP

B Hyp f br n gen states need ry pre p tate.

C Hyp therm a and ac d s s: nh b t pr per l tt ng me han sms

VI Me dic a lly induc e d

A Asp r n: permanently b nds y l xygenase (COX), prevent ng platelet aggregat n

B Plav x: bl ks aden s ne d ph sphate (ADP)–med ated platelet aggregat n

C Gp IIb/IIIA nh b t rs: nh b t platelet aggregat n

D War ar n: bl ks v tam n K–dependent l ver synthes s a t rs II, VII, IX, and X

E Hepar n and hepar n ds: augment ant thr mb n-III un t n

F L w-m lecular-we ght hepar n: nh b ts a t r Xa

G D rect thr mb n nh b t rs: argatr ban, dab gatran

H Fact r Xa nh b t rs: ap xaban

I F br n lyt cs: t ssue plasm n gen a t vat r (tPA), ur k nase, et ,

med ate f br n lys sVII He m ophilia

A Hem ph l a A: C ngen tal de en y a t r VIII;

treatment s a t r repla ement FFP an be used n emergent

s tuat ns

B Hem ph l a B: C ngen tal de en y a t r IX; treatment

s a t r repla ement FFP an be used n emergent

s tuat ns

VIII von Wille bra nd dis e a s e : T e m st mm n ngen tal

agul pathy (1%–2% adults) s def en y v n W llebrand

a t r reatment s ntranasal DDAVP n m ld ases, IV DDAVP

pr r t surg al pr edures, and ry pre p tate r FFP n emergen es

IX Othe rs : aut mmune d seases, an er, snake ven m

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The TEG is rapidly becoming the s tandard o care tes t to identi y bleeding dis orders in trauma patients and in the intens ive care unit (ICU).

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Recombinant activated actor VII (r VIIa) is approved or us e in treating hemophiliacs who have developed antibodies to actors VIII and IX Although not replacing the mis s ing actors , s upraphys iologic dos es o r VIIa caus e a thrombin burs t and clot to orm, which has led to s tudy

o its e cacy to treat other coagulopathies , including war arin therapy when quick revers al is needed (i.e., intracranial bleed) and in s evere traumatic coagulopathy.

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Spe c if c Hyp e rc oa g ula b le Sta te s

I Surgic a l pa tie nts : Surgery, trauma, and seps s ause pr n ammat ry states that lead t a hyper agulable state; there re, surg al pat ents are at r sk r

deep ven us thr mb s s (DV ).

A Maj r r sk a t rs n lude maj r abd m nal r pelv surgery;

rth ped surgery, espe ally l wer extrem ty; trauma, espe ally sp ne, pelv s, and l wer extrem ty ra tures; pr l nged

mm b l zat n; an er; sm k ng; bes ty; entral l ne pla ement;

and thers

B Hepar n 5,000 un ts sub utane usly every 8 h urs r l

w-m le ular-we ght hepar n sub utane usly da ly r tw e da ly

sh uld be used; n pat ents wh have ntra nd at ns t pr phylax s ( ntra ran al bleed), n er r vena ava f lters sh uld be ns dered

II Conge nita l ris k a c tors : Suspe t pat ents have mult ple DV

r DV w th ut an ther kn wn r sk a t r; treatment s usually ant agulat n

A Pr te n S de c ency

B Pr te n C de c ency

C Fact r V Le den mutat n

D Ant thr mb n III mutat ns

E Others

PACKED RED BLOOD CELL TRANSFUSION THERAP Y

Tra ns us io n Ris ks

I Fe brile re a c tions /a lle rgic : m os t c om m on im m une re a c tion

A Usually related t e ther yt k nes r d n r leuk yte r ther

ntam nants r a m ld ant b dy resp nse and s usually sel -l m ted

B Can be prevented by leuk deplet n and pretrans us n

ant pyret s

II Ele c trolyte dis turba nc e s

A Hyperkalem a: Lysed ells an ause hyperkalem a.

B Hyp calcem a: C trate n st red bl d an b nd al um.

III Coa gulo pa thy: Pa ked red bl d ells (pRBCs) d n t nta n l tt ng a t rs r platelet

Large-v lume trans us n w th ut these ther pr du ts an ause a agul pathy

IV ABO inc om pa tibility

A Et l gy: ntravas ular mmune rea t n, lead ng t lump ng

and lys s red ells w th m smat hed bl d

B S gns and sympt ms: hem gl b nur a, ever, h lls,

agul pathy, renal a lure, and r ulat ry llapse

V De la ye d he m olytic re a c tion: usually takes 3–7 days t man est

A S gns and sympt ms: ever, mala se, hyperb l rub nem a, and

de reas ng hemat r t, usually related t m n r ant b dy systems (e.g., Rh system)

B Usually but n t always preventable w th re p ent ant b dy

s reen ng

C reatment: hydrat n and supp rt ve are

VI Dis e a s e tra n s m is s io n : Many v ruses are transm tted by bl d, wh h was n e a real r sk

W th m dern s reen ng meth ds (e.g., nu le a d te hn l gy), the r sk s the ret al and negl g ble

A HIV: est mated t be 1:2,000,000

B Hepat t s C: est mated t be 1:2,000,000

C Hepat t s B: est mated t be 1:2,000,000

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Always as s es s your s urgical patients or thromboembolic prophylaxis Mos t hos pitals have protocols now that mus t be ollowed.

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There are more than 100 mutations known to caus e hypercoagulability.

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The longer blood is

s tored, the wors e it per orms Over time, cells lys e, and 2,3-diphos phoglycerate (2,3-DPG) levels all, caus ing oxygen to bind more avidly.

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ABO incompatibility prevention is key by ens uring correct patient identity

and blood type to avoid cons equent preventable reactions.

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16 Chapter 1 Pa ked Red Bl d Cell rans us n T erapy

D Others: R sks less kn wn but have been des r bed Human

t-lymph tr p v rus (H LV) 1 and 2, West N le v rus, Creutz eldt-Jak b d sease; verall r sk v ral transm ss n may

be as h gh as 1:50,000

VII Im m uno s uppre s s io n: Negat ve ut mes n lude the ll w ng:

A M rb d ty: n reased n ect us c mpl cat ns, n lud ng

vent lat r-ass ated pneum n a

B P ss ble n reases n cancer recurrence ll w ng p tent ally

urat ve surgery

C Increased m rtal ty: n ICU pat ents

Tra ns us io n Ind ic a tio ns

I Ac ute c orona ry dis e a s e : Standard tr gger s 8 g/dL

II Tra um a p a tie nts : Exsangu nat ng pat ents ( lass III sh k) sh uld

be g ven bl d as resus tat n

A T e r Hgb measurement may st ll be h gh a utely, but they are

l s ng bl d and ts attendant xygen- arry ng apa ty

B Bl d/FFP rat s are be ng urrently stud ed, but resus tat n

w th 1:1 rat bl d/FFP w th platelets every urth r und and

m n mal t n rystall d

III ICU pa tie nts : I needed, d re t measurements xygen del very

and xygen extra t n an help t gu de trans us n therapy t determ ne extra xygen- arry ng apa ty s needed

IV Ge ne ra l (no n-ICU) pa tie nts : nly trans use sympt mat

(e.g., ta hy ard a, ta hypnea, n us n, lethargy, and a d s s)

Tra ns us io n Alte rna tive s

I Ele c tive s urge ry ( the t me bl d l ss s kn wn)

A Aut l g us banked bl d

B Ep et n alpha: an n rease h t pre perat vely t help av d

trans us n; use ul n renal a lure pat ents and th se w th

hr n anem a

C Aut trans us n: re y le bl d l st dur ng surgery

D Acute n rm v lem c hem d lut n

1 On e a pat ent s anesthet zed, bl d an be rem ved, st red,

and repla ed w th rystall d r ll d t ma nta n euv lem a

2 Bene ts

a Bl d l st dur ng surgery has a l wer h t; there re, ewer

red ells are shed

b T se that are shed an be repla ed w th resh (n t st red)

aut l g us bl d that was just rem ved

E D rected d n r: R sk v rus transm ss n s l wer, but s m lar

r sks mmun m dulat n and ther rea t ns ex st

F Hem stat c agents: prevent bl d l ss n the f rst pla e

1 FFP/cry prec p tate: r pat ents w th agul pathy

2 DDAVP: r platelet dys un t n, espe ally renal a lure

3 ranexam c ac d: nh b ts ser ne pr teases, n lud ng

plasm n, and s there re ant f br n lyt ; n reas ngly used n trauma

4 Lys ne anal gs: -am n apr a d

5 p cal hem stat cs: f br n glue

II Ac ute une xp e c te d blood los s

A Aut trans us n: may st ll be an pt n, read ly ava lable

s et Transfusion decisions should be based on individual patient circumstances In

general, it is s a e to let the Hgb drop to 7 mg/dL and even lower in healthy, young individuals.

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Patients with acute coronary syndromes may need higher Hgb levels , but this is debatable.

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An Hgb trans usion trigger o 7 is as sa e as 10 and reduces complications even in those with a history o cardiac disease.

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Is otonic f uids can be used to s upport intravas cular volume.

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Quick prevention

o urther blood los s is the bes t therapy or unexpected blood los s.

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Blood is an immunos uppres s ant

as s ociated with advers e outcomes in s urgical patients Only us e when needed.

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NUTRITION AND THE SURGICAL PATIENT

Ene rg y So urc e s : Pro te in, Gluc o s e , a nd Fa t

I Pro te in

A Requ res nvers n t glu se v a hepat glu ne genes s t be used as a al r uel s ur e

B Adequate ntake s mp rtant r mus le mass ma ntenan e and ther pr te n-dependent,

A Basal metab l c rate (BMR): am unt energy used by an

unstressed, asted nd v dual at rest

B Rest ng energy expend ture (REE): am unt energy used by

an unstressed, n n asted nd v dual at rest

C tal energy expend ture ( EE): a tual am unt energy an

nd v dual uses

1 EE an n rease s gn f antly ab ve REE by hypermetab l

nd t ns (e.g., surgery, trauma, seps s, and burns)

2 EE an n reased by v luntary w rk (e.g., exer se), whereas

dur ng starvat n, the BMR de reases as the b dy adjusts t nserve b dy mass Cal r requ rements an be determ ned

by nd re t al r metry r the F ck equat n

II Pro te in Re quire m e nts

A N rmal

1 L w be ause ea h pr te n m le ule has a spe f purp se and s there re n t generally ava lable

as an energy s ur e

2 Generally, da ly pr te n requ rements are nly 0.8–1.0 g/kg/day, wh h s s gn f antly less than

the average Amer an eats da ly

B Starvat n

1 T e b dy makes every attempt t nserve pr te n Be ause gly gen st res are metab l zed

w th n the f rst 24 h urs starvat n, an ther s ur e glu se must be und r the t ssues that ann t, r usually d n t, use ats ( e., bra n ells, red and wh te bl d ells) Pr te ns are

br ken d wn and nverted t glu se n the l ver by gluc ne genes s t supply the bra n and

bl d ells w th glu se

2 In unstressed starvat n, pr te n atab l sm an be prevented by ex gen us adm n strat n

glu se T e bra n adapts t use ket nes, wh h are pr du ed when at s metab l zed, and

de reases the am unt pr te n that must be metab l zed as a glu se s ur e A er all the ava lable at s metab l zed, pr te n s degraded at a h gh rate unt l the t tal b dy pr te n st res are ½ basel ne, at wh h t me death urs

C Severe llness

1 T e b dy s n t able t nserve energy and pr te n st res as t d es dur ng unstressed starvat n.

2 T e h rm nal m l eu n reases the BMR, de reases the ab l ty t use ats and ket nes, and

thereby n reases the dependen e n glu se as an energy s ur e T s glu se an me nly

r m pr te n that s be ng degraded

3 As the degree llness r njury n reases, the catab l c rate n reases a rd ngly, lead ng

t a rap d breakd wn pr te n st res and mult rgan dys un t n n t he ked Dur ng the

a ute phase severe llness r stressed starvat n, pr te n atab l sm s m n mally a e ted by

ex gen us adm n strat n glu se

4 Pr mary treatment: El m nate the underly ng ause the stress resp nse and pr v de en ugh

al r es and pr te n t repla e metab l and atab l l sses

5 As the llness beg ns t subs de, the h rm nal m l eu hanges, wh h leads t less retent n

salt and water and a hange r m a atab l pr te n env r nment t an anab l c env r nment

T e n tr gen balan e s p s t ve, mean ng that less n tr gen s l st than s adm n stered t the pat ent T s balan e represents pr te n that s be ng la d d wn and thus mpr vement the pat ent’s health

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REE is 1.2 times the BMR or 25 kcal/kg/day.

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Fever increas es the TEE 10% or each increas e

in degree Cels ius ; trauma/

burns can double TEE.

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18 Chapter 1 Nutr t n and the Surg al Pat ent

Nutritio n Sta tus Eva lua tion

I Thin, c a c he c tic pa tie nt: Exh b ts h ll wed heeks, n b dy at, and very l ttle mus le and s

bv usly n a p r nutr t nal state Generally, pat ents wh have a utely l st 10% the r b dy we ght are ns dered maln ur shed and need nutr t nal supp rt

II Ob e s e pa tie nt a nd we ll-de ve lo pe d p a tie nts : may need as mu h nutr t nal supp rt as the pat ent n a p r nutr t nal state, depend ng n the underly ng d sease pr ess

III Pre vious ly we ll-nouris he d pa tie nt: Generally able t endure a

maj r perat n and 5–10 days starvat n w th ut an n rease n

m rb d ty r m rtal ty I the per d starvat n extends bey nd

10 days, nutr t nal supp rt s ne essary

IV Pa tie nts with s e ve re illne s s : I unable t eat r m re than

10 days be ause surgery, ns der early nutr t nal supp rt

Be ause t takes several days t take e e t, beg nn ng su h supp rt there s any quest n nutr t nal def t s m re e e t ve than

wa t ng unt l a severe def t urs

The ra py

I Goa ls : T e average h sp tal zed pat ent requ res 2,000 al da ly and 60 g pr te n

A Energy: Determ ne al r requ rements t pr v de adequate

energy substrates ( e., arb hydrates, ats) and av d ex ess

al r es n ne ur ways

1 Ind rect cal r metry: Measures am unt xygen nhaled

m nus am unt xygen exhaled t determ ne am unt xygen nsumed Be ause xygen nsumpt n (VO2) measured n mL O2/m n s d re tly rrelated t

k al/day (1 mL O2/m n 7 k al/day), measurement the am unt xygen nsumed an determ ne da ly al r requ rements

2 F ck equat n: Am unt xygen nsumed, and there re

k al requ red, s determ ned by mult ply ng the ard a utput

by the arter ven us xygen ntent d eren e

3 Harr s-Bened ct equat ns: Da ly al r requ rements are

determ ned by al ulat ng REE r m gender-based equat ns

us ng gender, he ght, we ght, and age var able and then mult ply ng by an est mated stress a t r

4 Est mated REE (25 kcal/kg/day): mult pl ed by an est mated

stress a t r

B Pr te n: Determ ne pr te n requ rements n ne ur ways.

1 N tr gen balance: T e maj r ty atab l zed pr te n s l st

as ur nary urea n tr gen, w th 2–4 g n tr gen l st n st l

Pr te n grams d v ded by 6.25 equals n tr gen grams Am unt

n tr gen ntake m nus n tr gen utput sh uld be p s t ve adequate pr te n s g ven and the pat ent s n t t atab l

2 V sceral pr te n measurement (e.g., album n, trans err n, prealbum n)

a Due t the l ng hal -l e album n, t sh uld nly be used

t assess malnutr t n n utpat ent and ele t ve surgery pat ents

b Prealbum n has a sh rter hal -l e and s m re re e t ve

pr te n nutr t n n h sp tal zed pat ents

c A C-rea t ve pr te n (CRP) sh uld be he ked be ause

elevated levels n ammat n (trauma/seps s/burns) w ll alter v s eral pr te n pr du t n away r m prealbum n synthes s

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The overall goal o nutritional support is to supply adequate energy in the orm o calories and adequate protein

or building proteins in the body

blood, and Cv oxygen concentration o mixed venous blood Ca Cv is also known

as the arteriove nous oxyge n

di erence.

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Harris -Benedict gender-bas ed equations : Men: BMR 88.362 (13.397 weight in kg) (4.799 height in cm) (5.677 age in years )

Women: BMR 447.593 (9.247 weight in kg) (3.098 height in cm) (4.330 age in years )

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The protein requirement or most adults

is 0.8 g/kg/day (or 56 g

or the hypothetical 70-kg patient) During severe illness with a high catabolic rate, this requirement may increase to

2 g/kg/day o protein or greater.

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3 We ght ga n (p r meth d): Be ause m st pat ents need ng

nutr t nal supp rt n the h sp tal are stressed, they tend

t reta n water and be me edemat us Als , they w ll be atab l and l se lean b dy we ght desp te the n rease the r a tual b dy we ght r m u d ga n

4 Observe the verall c nd t n the pat ent (best verall meth d): Obta n n tr gen balan es (max mum tw e

weekly), ll w v s eral pr te ns (prealbum n/CRP tw e weekly), and n rease pr te n adm n strat n (alth ugh there

s n the ret al l m t t the max mum am unt pr te n that an be adm n stered, pr te n n ex ess the pat ent’s needs w ll result n a r se n bl d urea

n tr gen [BUN])

II En te ra l n u tritio n : he pre erred r ute t pr v de nutr t n

s enterally t ma nta n gut mu sal ntegr ty and redu e mpl at ns he gut s mp rtant n r t ally ll pat ents;

unused r even br e per ds, the mu sa beg ns t atr phy and l se ts barr er un t n, lead ng t ba ter al transl at n and w rsen ng system n lammat n In add t n t transl at n, the atr ph ed mu sa s unable t d gest d when d s ult mately presented, wh h leads t urther delays n adequate nutr t n

A F rmula c mp s t ns: When p ss ble, pat ents sh uld be ed by m uth; h wever, w th r t al

llness, asp rat n r sk, depressed mental status, r nab l ty t take adequate al r es r pr te n rally, adm n strat n enteral eed ng rmulas s ne essary T ese rmulas are des gned t

pr v de adequate nutr t n and may be r ut ne r nes that are h ghly spe al zed t serve the needs

un que pat ent p pulat ns

1 Standard rmulas: su table r m st pat ents

a Pr v de a balan ed al r e/pr te n rat w th 50%–65% al r es r m arb hydrates,

10%–20% r m pr te ns, and the rest r m ats

b Cal r dens ty s 1.0–1.2 k al/mL; they n lude the essent al ats, m nerals, and tra e

elements

2 Elemental rmulas: am n a d r small pept de–based r ease d gest n and l wer res due

n pat ents w th sh rt gut syndr me r d stal enter utane us f stulas

3 Cal r e-dense rmulas: nta n m re al r es per m ll l ter than standard rmulas

(typ ally 1.5–2.0 k al/mL) r pat ents need ng u d restr t n r very h gh al r requ rements

4 Pr te n-dense rmulas: pr v de n reased pr te n (20%–25% al r es) r pat ents w th very

h gh pr te n needs

5 Fat-based rmulas: pr v de m re al r es r m ats rather than glu se and attempt t redu e

CO2 pr du t n by alter ng the resp rat ry qu t ent r pat ents w th mpr m sed m nute vent lat n (e.g., severe hr n bstru t ve pulm nary d sease [COPD] and a ute resp rat ry

d stress syndr me [ARDS] pat ents)

6 Immun m dulat ng rmulas: Pr v de glutam ne and typ ally mega-3 atty a ds t enhan e

mmun l g un t n; h wever, e a y s m xed S me re mmend them r me han ally vent lated pat ents w th system n ammat ry resp nse syndr me (SIRS) r m seps s, trauma, burns, a ute lung njury (ALI), et

B Adm n strat n r ute

1 Enteral nutr t n rmulas an be del vered by tubes pla ed nt the GI tra t d re tly

(gastr st my, eed ng jejun st my) r v a the n se (nas gastr , nas du denal, r nas jejunal)

2 An abd m nal rad graph t determ ne pr per tube pla ement sh uld be bta ned pr r t

start ng tube eed ngs n eed ng tubes pla ed rally r nasally at the beds de

3 P stpyl r pla ement (jejun st my, nas du denal, nas jejunal) s ass ated w th earl er

t leran e but s m re d ult, lead ng t p tent al delays n n t at n enteral nutr t n

4 Early n t at n enteral nutr t n ( 48 h urs) s ass ated w th ewer mpl at ns and

sh uld be used even n the mmed ate p st perat ve per d ll w ng abd m nal surgery r trauma

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When determining whether nutritional s upport

is adequate or hos pitalized patients , obs erving the

patient’s overall condition is better than monitoring weight gain alone.

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Us e the gut or eeding whenever pos s ible.

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20 Chapter 1 Nutr t n and the Surg al Pat ent

C Adm n strat n rate: Enteral nutr t n sh uld be started as nt nu us n us n.

1 A reas nable start ng p nt s ull strength at 20 mL/hr and n reased by 20 mL/hr every

6–12 h urs unt l the g al rate s bta ned r ex ess ve res duals are n ted

2 T e g al rate s determ ned by the pat ent’s al r needs and the al r dens ty the rmula.

3 Gastr res dual v lumes tube eed ngs sh uld be he ked every 4 h urs r ex ess ve res dual

v lumes ( 500 mL), even eed ngs are p stpyl r

a I res dual v lumes are h gh, the n us n sh uld be st pped and then resumed a er 4 h urs.

b I res duals nt nue t be h gh, the ause ( leus, bstru t n) sh uld be s ught.

D C mpl cat ns

1 Gastr ntent asp rat n s the m st mm n mpl at n

enteral nutr t n but an be redu ed by m n t r ng res dual

v lumes and ma nta n ng the head the bed up 30 degrees

2 Bl at ng, mesenter s hem a (rare), and d arrhea may ur

w th tube eed ngs, but adjustments n mp s t n and rate

an m n m ze these ssues

3 Inadequate nutr t nal supplementat n aused by requent

eed ng essat n s n t un mm n unless n erted e rts are made t av d t

III Pa re nte ra l (IV) nutrition: PN all ws the pr v s n adequate nutr t n when the GI tra t s usable

due t malabs rpt n, bstru t n, f stulas, r anat m hanges C mb ned enteral and parenteral adm n strat n s s met mes benef al

A F rmula c mp s t n: PN s lut ns sh uld nta n mp nents nutr t nal requ rements

be ause ther s ur es may n t be ava lable

1 Carb hydrates: Pred m nantly as glu se s lut n; pr v de 50% t tal al r es and ause

PN t have a h gh sm lal ty Part al ( r per pheral) parenteral nutr t n (PPN) nta ns l wer

n entrat n glu se and s n t s gn f antly hyper sm lar

2 Am n ac d s lut n: pr v de 10% t tal al r es and mp rtantly pr v d ng essent al am n

a ds r metab l sm, espe ally n hyper atab l pat ents

3 Fats: adm n stered e ther nt nu usly r nterm ttently as l p d emuls n and are ne essary t

av d essent al atty a d def en y

a L p d emuls ns als pr v de the m st al r es n the smallest v lume ( at has the h ghest

al r dens ty) and pr du e less CO2 (l west resp rat ry qu t ent), wh h may be mp rtant

n pat ents w th v lume restr t ns r mpr m sed vent lat n

b Adm n strat n l p d emuls ns an lead t hypertr gly er dem a; levels sh uld be r ut nely

m n t red

4 Electr lytes: n lude the m n valent at ns, s d um and p tass um; the d valent at ns,

al um and magnes um; and the an ns, hl r de and a etate ( nverted t b arb nate n the

l ver), wh h an be adjusted as needed

5 V tam ns and trace elements: Must be pr v ded t av d a qu red def en es; spe f ally, the

ex gen us adm n strat n B v tam ns, v tam n E/selen um (l p d per x dat n and ree rad al

s aveng ng), z n (w und heal ng, mmun ty), and hr m um ( nsul n sens t v ty) sh uld be

ns dered n pat ents re e v ng PN

6 Med cat ns: May be n rp rated nt PN; parenteral stress ul er pr phylax s med at ns and

nsul n are the m st requently added

B Adm n strat n r ute: usually v a a per utane usly pla ed

ven us l ne w th the t p l ated n the vena ava

C Adm n strat n rate: PN s typ ally pr v ded nt nu usly at

a rate that pr v des adequate al r es t meet the pat ent’s needs and depends n al r dens ty and degree hypermetab l sm

1 C mm nly, pat ents are started at hal the g al rate r 12 h urs

be re advan ng t the ull rate t av d severe hypergly em a

2 S me adv ate de reas ng the PN rate by hal r 6–12 h urs

pr r t st pp ng t av d hyp gly em a

3 Cy l ng t all w pat ents t be d s nne ted r per ds

t me dur ng the day an be a mpl shed but sh uld nly be pres r bed by exper en ed pers nnel and n sele ted pat ents

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Although s tudies conf ict, there appears to be

no bene t rom pos tpyloric eeding in terms o as piration, pneumonia, or outcomes

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The high os molality

o TPN caus es phlebitis and s cleros is i in us ed into a peripheral vein (les s hyperos molar PPN can be delivered via a peripheral vein but typically does not meet caloric needs ).

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